Provider Demographics
NPI:1851808802
Name:KOCH, IAN (MS, LCADC, CAS)
Entity Type:Individual
Prefix:
First Name:IAN
Middle Name:
Last Name:KOCH
Suffix:
Gender:M
Credentials:MS, LCADC, CAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 EDGEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:SOMERS POINT
Mailing Address - State:NJ
Mailing Address - Zip Code:08244-1613
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3 S WEYMOUTH AVE UNIT G
Practice Address - Street 2:
Practice Address - City:VENTNOR CITY
Practice Address - State:NJ
Practice Address - Zip Code:08406-2980
Practice Address - Country:US
Practice Address - Phone:609-709-0245
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-29
Last Update Date:2017-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37LC00214900101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
0OtherOTHER